Prior Authorization Specialist


ABOUT THE POSITION

The Prior Authorization Specialist will obtain authorizations for diagnostic imaging, cardiac imaging, prescription medications including hospital administered IV infusions, Veterans Administration authorizations, some durable medical equipment, and referral authorizations for some specialist appointments. This position will secure the prior authorization and notify the rendering party in the timeliest manner possible so our patient receives the services needed with the least delay.

RESPONSIBILITIES

  • Receive request for prior authorizations through the electronic health record (EHR) and/or via phone or fax and ensure that they are properly and closely monitored;
  • Process referrals and submit medical records to insurance carriers to expedite prior authorization processes;
  • Manage correspondence with insurance companies, physicians, specialist and patients as needed, including documenting in the EHR as appropriate;
  • Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed;
  • Review accuracy and completeness of information requested and ensure that all supporting documents are present;
  • Review denials and follow up with provider to obtain medically necessary information to submit an appeal of the denial;
  • Prioritize the incoming authorizations by level of urgency to the patient;
  • Secure patient information in accordance with CHCSEK policy/procedures;
  • Other duties as assigned.

QUALIFICATIONS

  • High school diploma or equivalent;
  • Previous experience in a clinic setting preferred;
  • Knowledge of insurance process and medical terminology preferred.

KNOWLEDGE, SKILLS AND ABILITIES

  • Social and cultural sensitivity appropriate to ethnically and economically diverse patient-and employee-base;
  • Communicates through appropriate channels. Use proper chain of command for patient complaints;
  • Ability to handle emergency situations calmly and effectively;
  • Must be computer literate and able to navigate through the Electronic Health Record;
  • Must be able to maintain good inter-personal relationship with co-workers and other members of the health care team and the organization;
  • Provide customer service in accordance to the organization's mission;
  • Be courteous and respectful when interacting with patients and family members;
  • Maintain patient confidentiality in accordance to organization's policy and procedure and HIPAA requirements.